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� F , <br /> APPLICATION FOR PERMIT V7 47/ <br /> �;ql SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIR�NMENTAI 1EALTH DIVISION <br /> " 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> Ii # PERMIT EXPIRES 1 YEAR FROM DATE_JSSUN2 <br /> (Complete in Triplicate) <br /> s <br /> Appliication is hereby made to San Joaquin County for a permit to construct and/or install the worts herein described. This <br /> t application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> I�I <br /> Job Address VlelrCit Size/Acreage <br /> OwnerNts Namet Mao. <br /> Phone <br /> 7 <br /> Con Irk for ddress L� )'` Iq 7 License No.1 bL_3 Phone <br /> TYPE[OF WELL/PUMP: NEW VVELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service We.21 ❑ <br /> PUMP INSTALLATION Cf' SYSTEM REPAIR OTHER ❑ Monitoring Well a <br /> DISTANCE TO NEAREST: SEPTIC TANK .SEWER LINES DISPOSAL FLD. PROP. LINE <br /> .ISM FOUNDATION AGRICULTURE VVgVL `+ OTHER WELL PITS/SUMPS <br /> t IN7ENDED"USE--TYPE OF-WELL-•- PROSLEM-AREA ---CONST.RUCTION_SPECIFICATIONS•---- <br /> n Industria! ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Welt Casing + <br /> C7 Domestic/Private U Gravel Pack 0 Tracy Type of Casing Specifications <br /> I'I Put lic i-1 Other 1 fl Delta Depth of Grout Seal Type of Grout <br /> } I I lrrig�etion _..4pprox. Depth i I Eastern Surface Seal Installed by <br /> I RepairlWork Done f;�- Type of Pump 9It-h t H.P. ZZ: _. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth s <br /> I�. Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW:INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is <br /> I available within 200 feet.) <br /> Installation will serve: Residence_' Commercial-_ Other I -- M-- -T -f <br /> t <br /> f Number of living units: Number of bedrooms <br /> Cha r�hctor of soil to a depth of a feet: k ,�-, ,z�,:1�1 Water table depth <br /> _ <br /> r SEPTIC TANK. ❑ Type/Mfg ° Ca "pacity t No. Compartments <br /> rfPKG. TREATMENT PLT. Cl .--._-,.w..---_...-.----�-..._--. Disposal <br /> Method o Di osal <br /> Distance to Clearest: Well Foundation Property Line '' <br /> LEACHING LINE Cl No, & Length of lines Torsi length/size <br /> FILTER'BED 0 Distance to nearest; Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number + <br /> phi <br /> SUMPS 13 . Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I f <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> k rules and regul i soft an Joaquin County # <br /> I4 Home own r licensed age 's sign ure cenif the following: 1 certify that in the performance of the work for which this permit is issued, I shall not <br /> employ, person in such nner as o beco e s biect to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifie ;the following: "I c ify th i t orm nce of the work for which this permit is issued, I shall employ pers�ns subject to workman's compensa- <br /> tion I ws of- lifornia." <br /> The ap�pllicant c II r all r plate drawing n se <br /> Sig d1` Title: _ '� w'L Date: 1— <br /> FO DEPARTMENT USE ONLY <br /> �`�, 4 �� <br /> Application Accepted by Date Area <br /> I` <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> ` Additiont I Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> i Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE MOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. <br /> VU <br /> r EH 13-241REV. <br /> E .s�esi /]0 J <br /> , M".4-26 .2 p 7 <br />